Médecine sociale en 2013 : quand la précarité précède la pauvreté [Social medicine : does it still make sense in 2013?]

Social medicine is a medicine that seeks to understand the impact of socio-economic conditions on human health and diseases in order to improve the health of a society and its individuals. In this field of medicine, determining the socio-economic status of individuals is generally not sufficient to explain and/or understand the underlying mechanisms leading to social inequalities in health. Other factors must be considered such as environmental, psychosocial, behavioral and biological factors that, together, can lead to more or less permanent damages to the health of the individuals in a society. In a time where considerable progresses have been made in the field of the biomedicine, does the practice of social medicine in a primary care setting still make sense? La médecine sociale est une médecine qui cherche à comprendre l'impact des conditions socio-économiques sur la santé humaine et les maladies, dans la perspective d'améliorer l'état de santé d'une société et de ses individus. Dans ce domaine, la détermination du statut socio-économique des individus ne suffit généralement pas à elle seule pour expliquer et comprendre les mécanismes qui sous-tendent les inégalités sociales de santé. D'autres facteurs doivent être pris en considération, tels que les facteurs environnementaux, psychosociaux, comportementaux et biologiques, facteurs qui peuvent conduire de manière synergique à des atteintes plus ou moins durables de l'état de santé des individus d'une société. A une époque où les connaissances, les compétences et les moyens à disposition en biomédecine ont fait des progrès considérables, la pratique de la médecine sociale en cabinet a-t-elle encore sa place en 2013?

Sleep deprivation induces transcriptional modifications of genes related to astrocyte-neuron lactate shuttle in astrocytes

Astrocytes play a key role in the neurometabolic coupling through the glycogen metabolism and the ''Astrocyte-Neuron Lactate Shuttle'' (ANLS). We previously reported that brain glycogen metabolism was affected by sleep deprivation (SD). Therefore, it is of prime interest to determine if a similar sleep loss also affects the ANLS functioning in astrocytes. To address this issue, we sleep deprived transgenic mice expressing the GFP under the control of the GFAP promoter and in which astrocytes can be isolated by FACS. The levels of expression of genes related to ANLS were assessed by qRT-PCR in the GFP-positive cells (GFPþ). The FVB/NTg( GFAP-GFP)Mes14/j mice were weaned at P20-P21 and underwent an instrumental 6 h SD at P23-P27. The SD was realized using the ''CaResS'' device which has been designed to minimize stress during SD. Control group corresponds to undisturbed mice. At the end of SD, mice were sacrificed and their cerebral cortex was rapidly dissected, cut in small pieces and enzymatically digested. After cell dissociation, GFPþ and GFP- cells were sorted by FACS and treated for RNA extraction. A quantitative RTPCR was realized using specific probes against different genes involved in ANLS. Results indicate that genes encoding the LDHb, the GLT1, the alpha2 subunit of the Na/KATPase pump as well as the GLUT1, were significantly increased in the GFPþ cells from SD mice. No significant change was observed in the GFP- cells from the same group. These results indicate that this approach is suitable to determine the transcriptional signature of SD in glial cells from juvenile animals. They also indicate that sleep loss induces transcriptional changes of genes involved in ANLS specifically in astrocytes. This could suggest that an adaptation of the ANLS at the transcriptional levels exists in pathophysiological conditions where neuronal activity is enhanced.

Factors influencing interprofessional practices of physiotherapists working in private settings with people with low back pain: a qualitative study

Purpose: Collaboration and interprofessional practices are highly valued in health systems everywhere, partly based on the rationale that they improve outcomes of care for people with complex health problems, such as low back pain. Research in the area of low back pain also supports the involvement of different health professionals in the interventions for people who present this condition. The aim of this studywas to identify factors influencing the interprofessional practices of physiotherapists working in private settings with people with low back pain. Relevance: Physiotherapists, like other health professionals, are encouraged to engage in interprofessional practices in their dailywork. However, to date, very little is known of their interprofessional practices, especially in private settings. Understanding physiotherapists' interprofessional practices and their influencing factors will notably advance knowledge relating to the organisation of physiotherapy services for people with low back pain. Participants: Participants in this study were 13 physiotherapists including 10 women and 3 men, having between 3 and 22 years of professional experience, and working in one of 10 regions of the Province of Quebec (Canada). In order to obtain maximal variation in the perspectives, participants were selected using a recruitment matrix including three criteria: duration of professional experience, work location, and physical proximity with other professionals. Methods: Thiswas a descriptive qualitative study using faceto- face semi-structured interviews as the main method of data collection. An interview guide was developed based on an evidence-derived frame of reference. Each interview lasted between 55 and 95 minutes and was transcribed verbatim. Analysis: Qualitative analyses took the form of content analysis, encompassing data coding and general thematic regrouping. NVivo version 8 was used to assist data organisation and analysis. Results: Multiple factors influencing the interprofessional practices of physiotherapists were identified. The main factors include the consulting person's health condition, the extent of knowledge on health professionals' roles and fields of practice, the proximity and availability of professional resources, as well as daily work schedules. Conclusions: Our findings highlight the influence of multiple factors on physiotherapists' interprofessional practices, including professional practice and organisational issues. However, further research on the interprofessional practices of physiotherapists is still required. Research priorities targeting the views of other health professionals, as well as those of services users, would enhance our comprehension of interprofessional practices of physiotherapists. Implications: This study provides new insights that improve our understanding of the interprofessional practices of physiotherapists working in private settings with people with low back pain, more specifically on the factors influencing these practices. Based on our findings, implementing changes such as improving current and future health professionals' knowledge of the fields and roles of other health professionals through training may contribute to positively influencing interprofessional practices. Keywords: Interprofessional practices; Private practice; Low back pain Funding acknowledgements: This research was supported in part by a B.E. Schnurr Memorial Fund Research Grant administered by the Physiotherapy Foundation of Canada, as well as from a clinical research partnership in physiotherapy between the Quebec Rehabilitation Research Network (REPAR) and the Ordre professionnel de la physiothérapie du Québec (OPPQ). KP received doctoral-level scholarships from the Canadian Institutes of Health Research (CIHR) and the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST). CE Dionne is a FRSQ senior Research Scholar. Ethics approval: This project was approved by the ethics research committee of the Institut de réadaptation en déficience physique de Québec.

Assessment of youth-friendly health care: a systematic review of indicators drawn from young people's perspectives.

PURPOSE: To review the literature on young people's perspectives on health care with a view to defining domains and indicators of youth-friendly care. METHODS: Three bibliographic databases were searched to identify studies that purportedly measured young people's perspectives on health care. Each study was assessed to identify the constructs, domains, and indicators of adolescent-friendly health care. RESULTS: Twenty-two studies were identified: 15 used quantitative methods, six used qualitative methods and one used mixed methodology. Eight domains stood out as central to young people's positive experience of care. These were: accessibility of health care; staff attitude; communication; medical competency; guideline-driven care; age appropriate environments; youth involvement in health care; and health outcomes. Staff attitudes, which included notions of respect and friendliness, appeared universally applicable, whereas other domains, such as an appropriate environment including cleanliness, were more specific to particular contexts. CONCLUSION: These eight domains provide a practical framework for assessing how well services are engaging young people. Measures of youth-friendly health care should address universally applicable indicators of youth-friendly care and may benefit from additional questions that are specific to the local health setting.

Minocycline Promotes Remyelination in an In Vitro Model of Demyelination

Brain inflammation plays a central role in numerous brain pathologies, including multiple sclerosis (MS). Microglial cells and astrocytes are the effector cells of neuroinflammation. They can be activated by agents such as interferon-g (IFN-g) and lipopolysaccharide (LPS). Aggregating brain cultures exposed to a repeated treatment (3 fold) with IFN-g (50 U/ml) and LPS (5 ug/ml) were used as an in vitro model of demyelination. Demyelination could be due to either the direct effect of IFN-g and LPS on oligodendrocytes or the IFN-g and LPS-induced inflammatory response. We investigated the involvement of microglial reactivity in demylination and remyelination by using minocycline, an antibiotic known to block microglial reactivity. Changes in myelination were examined by measuring the expression of myelin basic protein (MBP) and myelin oligodendrocyte glycoprotein (MOG) at the mRNA level by quantitative RT-PCR and at the protein level by Western blotting and immunohistochemistry. To evaluate brain inflammatory reactions, microglia were stained with isolectin B4 (IB4), quantitative RT-PCR was used to determine the expression of tumor necrosis factor-a (TNF-a), interleukin-6 (IL-6), and inducible NO synthase (iNOS). The repeated treatment with IFN-g and LPS caused demyelination, as indicated by a decrease in MBP and MOG expression. It also activated microglial cells, and up-regulated TNF-a, IL-6, and iNOS expression. Although minocycline did not affect the IFN-g- and LPS-induced upregulation of TNF-a, IL-6, it decreased the number of IB4-labeled microglial cells. Furthermore, minocycline did not prevent demyelination, whereas it strongly increased MBP expression one week after the end of the demyelinating treatment. In conclusion, the present results show that minocycline promoted remyelination after IFN-g- and LPS-induced demyelination, presumably due to its effects on microglial cells.

Relève en médecine interne générale: enjeux et perspectives [Perspectives and challenges to guarantee training and renewal in general internal medicine]

Training new doctors in general internal medicine represents a challenge. This requires to define future needs, which result from interest that are not necessarily convergent between patients, doctors, insurers and politicians. Problems related to medical demography in Switzerland, with the ageing of the population, the increase in health care costs and the place of Switzerland within the European Community require the implementation of specific objectives to train new physicians in general internal medicine. The success of these opportunities depends on social factors, political choices and choices from physician's association. In this article we will approach these challenges by formulating some proposals--nonexhaustive--in order to guarantee sufficient renewal in general internal medicine.

Health behaviours, socioeconomic status, and mortality: further analyses of the British Whitehall II and the French GAZEL prospective cohorts

BACKGROUND: Differences in morbidity and mortality between socioeconomic groups constitute one of the most consistent findings of epidemiologic research. However, research on social inequalities in health has yet to provide a comprehensive understanding of the mechanisms underlying this association. In recent analysis, we showed health behaviours, assessed longitudinally over the follow-up, to explain a major proportion of the association of socioeconomic status (SES) with mortality in the British Whitehall II study. However, whether health behaviours are equally important mediators of the SES-mortality association in different cultural settings remains unknown. In the present paper, we examine this issue in Whitehall II and another prospective European cohort, the French GAZEL study. METHODS AND FINDINGS: We included 9,771 participants from the Whitehall II study and 17,760 from the GAZEL study. Over the follow-up (mean 19.5 y in Whitehall II and 16.5 y in GAZEL), health behaviours (smoking, alcohol consumption, diet, and physical activity), were assessed longitudinally. Occupation (in the main analysis), education, and income (supplementary analysis) were the markers of SES. The socioeconomic gradient in smoking was greater (p<0.001) in Whitehall II (odds ratio [OR] = 3.68, 95% confidence interval [CI] 3.11-4.36) than in GAZEL (OR = 1.33, 95% CI 1.18-1.49); this was also true for unhealthy diet (OR = 7.42, 95% CI 5.19-10.60 in Whitehall II and OR = 1.31, 95% CI 1.15-1.49 in GAZEL, p<0.001). Socioeconomic differences in mortality were similar in the two cohorts, a hazard ratio of 1.62 (95% CI 1.28-2.05) in Whitehall II and 1.94 in GAZEL (95% CI 1.58-2.39) for lowest versus highest occupational position. Health behaviours attenuated the association of SES with mortality by 75% (95% CI 44%-149%) in Whitehall II but only by 19% (95% CI 13%-29%) in GAZEL. Analysis using education and income yielded similar results. CONCLUSIONS: Health behaviours were strong predictors of mortality in both cohorts but their association with SES was remarkably different. Thus, health behaviours are likely to be major contributors of socioeconomic differences in health only in contexts with a marked social characterisation of health behaviours. Please see later in the article for the Editors' Summary.

Well-being and the frailty process in later life: an evaluation of the effectiveness of downward social comparison

This article, which is based on a longitudinal study conducted with a cohort ofoctogenarians, examines downward social comparison and its effectiveness as an adjustment mechanism during the frailty process. First of all, a paradoxical stability of subjective well-being is to be observed: it remains stable over five years notwithstanding the general decline in health. Next, an analysis based on individual health trajectories reveals that downward social comparison is associated with the maintenance of a stable level of well-being, whereas, when it is not associated with well-being, the latter tends to vary.

Burnout and associated factors in employees of a Swiss teaching hospital

Background Working in a teaching hospital is a highly stressful occupation, which can lead to burnout. The consequences of burnout in health professionals can be very serious, both for themselves and patients. The aim of this cross-sectional study was to assess the extent of burnout and associated factors in hospital employees. Methods In the Fall of 2007, all employees of a Swiss teaching hospital were invited to complete a job satisfaction survey. It included the work-related burnout scale (scored 0-100) of the Copenhagen Burnout Inventory (CBI-French version), measuring the degree of physical and psychological fatigue and exhaustion perceived as related to the person's work; a high degree of burnout was defined as a score _50. Logistic regression analyses were used to determine factors associated with a high degree of burnout. Results A total of 4575 individuals returned the questionnaire (response rate 54%). Of them, 1503 (33%) had a high degree of burnout. The rate of burnout was higher among women (34.3% versus 30.5%, P = 0.012) and respondents younger than 40 years (37.7% versus 28.6%, P < 0.001). Executives were less prone to burnout than employees (27.1% versus 33.9%, P < 0.0019). Rates of burnout differed by profession: nurses and physicians had higher rates than administrative and logistic staff (42.8% and 37.4% versus 25.6% and 20.9%, respectively P < 0.001). Burnout was inversely associated with job satisfaction. In multivariate analysis, factors associated with burnout were overall dissatisfaction (OR 3.23; 95% CI 2.66-3.91), dissatisfaction with workload (OR 2.09; 95% CI 1.74-2.51) and work-life balance (OR 2.25; 95% CI 1.83-2.77), being a woman (OR 1.56; 95% CI 1.28-1.90), working fulltime (OR 1.41; 95% CI 1.08-1.85) and working as a nurse, a physician or in the psychosocial sector. Conclusions One-third of respondents, mostly nurses and physicians, experienced burnout and had lower levels of job satisfaction. The factors associated with burnout may help to tailor programmes aiming at reducing burnout at both the individual and organizational level within the hospital.

Characterization of the Morphological and Molecular Changes Associated with Diabetic Peripheral Neuropathy in Type 2 Diabetes

More than 246 million individuals worldwide are affected by diabetes mellitus (DM) and this number is rapidly increasing (http://www.eatlas. idf.org). 90% of all diabetic patients have type 2 DM, which is characterized by insulin resistance and b-cell dysfunction. Even though diabetic peripheral neuropathy (DPN) is the major chronic complication of DM its underlying pathophysiological mechanisms still remain unknown. To get more insight into the DPN associated with type 2 DM, we characterized the rodent model of this form of diabetes, the db/db mice. The progression of pathological changes in db/db mice mimics the ones observed in humans: increase of the body weight, insulin insensitivity, elevated blood glucose level and reduction in nerve conduction velocity (NCV). Decreased NCV, present in many peripheral neuropathies, is usually associated with demyelination of peripheral nerves. However, our detailed analysis of the sciatic nerves of db/db mice exposed for 4 months to hyperglycemia, failed to reveal any signs of demyelination in spite of significantly reduced NCV in these animals. We therefore currently focus our analysis on the structure of Nodes of Ranvier, regions of intense axo-glial interactions, which also play a crucial role in rapid saltatory impulse conduction. In addition we are also evaluating molecular changes in somas of sensory neurons projecting through sciatic nerve, which are localized in the dorsal root ganglia. We hope that the combination of these approaches will shed light on molecular alterations leading to DPN as a consequence of type 2 DM.

Workshop: Capacity building for national public health advocacy: case studies from national associations

The first statement of the EUPHA on the Future of Public Health in Europe refers to the need for going 'to policymakers, politicians and practitioners in all sectors of society and advise them on how to promote public health throughout society'. WHO-EURO Director General Marc Danzon, quoted in the second EUPHA statement on the responsibility of policy makers indicates that 'learning is not systematically applied in health policy development in our continent'. Statement 3 calls for the integration of public health into the political agenda in all sectors. The first EUPHA president, Louise Gunning-Schepers, quoted in Statement 10 called on EUPHA to become 'a powerful advocate of the public health community'. In addition to the above, the EU is now actively seeking ways to build capacity to implement its health strategy. Learning and building the capacity to achieve our aims The aims and objectives to promote the public's health as reflected in EUPHA's 10 statements are also mirrored in the national public health associations. However, many of EUPHA's national associations have little or limited experience in promoting public health policy at the national level. To assist in the learning of advocacy for public health policies, case studies presenting experiences of national public health organizations in lobbying for national public health policy will be presented and discussed. In addition to sharing experiences, the presentations will identify successful approaches to public health advocacy as well as lessons learned from unsuccessful attempts.

Mesenteric fat-control site for bacterial translocation in colitis?

In Crohn's disease bacteria could be detected in the adjacent mesenteric fat characterized by hypertrophy of unknown function. This study aimed to define effector responses of this compartment induced by bacterial translocation during intestinal inflammation. Dextran sulfate sodium-induced colitis served as a model of intestinal inflammation. Translocation of peptides and bacteria into mesenteric fat was evaluated. Innate functions of mesenteric fat and epithelium were characterized at whole tissue, cellular, and effector molecule levels. Orally applied peptides translocated in healthy wild-type (WT) mice. Bacterial translocation was not detected in healthy and acute but increased in chronic colitis. Mesenteric fat from colitic mice released elevated levels of cytokines and was infiltrated by immune cells. In MyD88(-/-) mice bacterial translocation occurred in health and increased in colitis. The exaggerated cytokine production in mesenteric fat accompanying colonic inflammation in WT mice was less distinct in MyD88(-/-) mice. In vitro studies revealed that fat not only increases cytokine production following contact with bacterial products, but also that preadipocytes are potent phagocytes. Colonic inflammation is accompanied by massive cytokine production and immune cell infiltration in adjacent adipose tissue. These effects can be considered as protective mechanisms of the mesenteric fat in the defense of bacterial translocation.

How many diagnosis fields are needed to capture safety events in administrative data? Findings and recommendations from the WHO ICD-11 Topic Advisory Group on Quality and Safety

OBJECTIVE: As part of the WHO ICD-11 development initiative, the Topic Advisory Group on Quality and Safety explores meta-features of morbidity data sets, such as the optimal number of secondary diagnosis fields. DESIGN: The Health Care Quality Indicators Project of the Organization for Economic Co-Operation and Development collected Patient Safety Indicator (PSI) information from administrative hospital data of 19-20 countries in 2009 and 2011. We investigated whether three countries that expanded their data systems to include more secondary diagnosis fields showed increased PSI rates compared with six countries that did not. Furthermore, administrative hospital data from six of these countries and two American states, California (2011) and Florida (2010), were analysed for distributions of coded patient safety events across diagnosis fields. RESULTS: Among the participating countries, increasing the number of diagnosis fields was not associated with any overall increase in PSI rates. However, high proportions of PSI-related diagnoses appeared beyond the sixth secondary diagnosis field. The distribution of three PSI-related ICD codes was similar in California and Florida: 89-90% of central venous catheter infections and 97-99% of retained foreign bodies and accidental punctures or lacerations were captured within 15 secondary diagnosis fields. CONCLUSIONS: Six to nine secondary diagnosis fields are inadequate for comparing complication rates using hospital administrative data; at least 15 (and perhaps more with ICD-11) are recommended to fully characterize clinical outcomes. Increasing the number of fields should improve the international and intra-national comparability of data for epidemiologic and health services research, utilization analyses and quality of care assessment.